Management of variceal bleeding

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Management of variceal bleeding

• Dr. Bennet Rajmohan, MRCSEd, MRCS (Eng)
• Consultant General Surgeon

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Introduction

• 30 of patients with cirrhosis develop portal
  hypertension
• 30 of patients with portal hypertension will
  bleed from varices within 2 years
• Incidence of varices in cirrhotics 8 / year

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Active variceal bleed

• 1 of 3 major complications of portal hypertension
  others ? ascites encephalopathy
• 1/3rd of all deaths related to cirrhosis
• Bleed occurs earlier in course of cirrhosis or
  with normal liver ? wider treatment options than
  for ascites encephalopathy

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Overview

• Treatment of an active bleed
• Prediction of patients at risk
• Prophylaxis against a first bleed
• Prevention of rebleeding

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Definitions

• Time zero time of admission to hospital
• Clinically significant bleeding
• 2 units of blood or more within 24 hrs of time
  zero
• systolic BP lt100 mmHg
• postural systolic change of gt20 mmHg
• and/or a pulse rate gt100/min at time zero

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Treatment of an active bleed
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GENERAL PRINCIPLES

• 3 primary goals
• Haemodynamic resuscitation
• Prevention treatment of complications
• Treatment of bleeding

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Hemodynamic resuscitation 

• Packed cells and clotting factors
• Platelet transfusions, if lt 50,000/mm3 active
  bleeding
• Avoid volume overload ? risk of rebound portal
  hypertension and rebleed

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Recombinant factor VIIa 

• Coagulopathy in severely volume overloaded ? FFPs
  inadequate
• At least 2 RCTs no clear benefit of recombinant
  factor VII
• awaits further clarification

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Prevention management of complications
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Complications ? death

1. Aspiration pneumonia
2. Sepsis
3. Hepatic encephalopathy
4. Renal failure

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Aspiration 

• Massive bleeding Endotracheal intubation to
  protect airway ? use unclear
• NG tube unclear
• Can decompress stomach for subsequent endoscopy

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2. Sepsis

• Bacterial infections 20 of cirrhotics
  hospitalized with GI bleed
• Additional 50 develop infection in hospital
• Most common
• UTI (12 29)
• SBP (7 23)
• respiratory (6 10)
• primary bacteraemia (4 11)

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Antibiotics

• overall ? in infectious complications
• possibly ? mortality
• ? risk of recurrent bleeding
• IV Ciprofloxacin x 7 days or Oral Norfloxacin
  (400mg bd)
• Advanced cirrhosis, IV Ceftriaxone (1G od)

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3. Hepatic encephalopathy

• aggressive search for potentially reversible
  factors
• GI bleed
• hypokalemia
• metabolic alkalosis
• Lactulose or L Ornithine

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4. Renal failure 

• acute tubular necrosis or hepatorenal syndrome
• minimized by
• appropriate volume replacement
• avoid aminoglycosides
• avoid mismatched transfusions

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Other measures

• Alcoholics
• Thiamine
• monitor for withdrawal symptoms
• Nutritionally depleted subjects
• hypophosphatemia hypokalemia
• dextrose infusions raise serum insulin ? drives
  both phosphate potassium into cells

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Treatment of bleeding
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Treatment

• Hepatic vein pressure gradient gt12mmHg
• 50 variceal bleed stops spontaneously vs gt 90
  in other forms of UGI bleed
• Options
• Pharmacotherapy
• Endoscopy
• Balloon tamponade
• Surgery

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Pharmacotherapy

• Terlipressin
• synthetic vasopressin analog released in slow
  sustained manner, 8th hrly doses
• sustained effect on portal pressure blood flow
  vs transient effect with octreotide
• Only drug which reduces mortality

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Pharmacotherapy

• Somatostatin
• 250 mcg bolus f/b 250 mcg/h by IV infusion x 5
  days
• Octreotide
• More easily available
• 50 mcg bolus f/b 50 mcg/h by IV infusion x 5 days

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Endoscopic Treatment 

• Endoscopist experience and expertise
• Grade of varices
• Grade 1 Small, straight varices
• Grade 2 tortuous varices occupying lt1/3rd of
  lumen
• Grade 3 Large, coil-shaped varices occupying gt
  1/3rd of lumen

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Endoscopic Sclerotherapy

• injection of sclerosant into varices
• Complications
• Local ulceration, bleeding, dysmotility,
  stricture portal hypertensive gastropathy
• Regional esophageal perforation mediastinitis

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Endoscopic band ligation 

• placing small elastic bands around varices in
  distal 5cm of oesophagus
• complications significantly lower
• much lower rate of oesophageal stricture
• reduction in rebleeding with Octreotide infusion
  endoscopic banding

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Endoscopic band ligation
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Failure of endoscopic therapy

• Within 48 hrs from time zero
• Reasons
• Spurting varices
• High Child-Pugh score
• High hepatic venous pressure gradient
• Infection
• Portal vein thrombosis

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Failure of therapy

• Within the first 6 hrs from time zero
• gt 4 units blood
• an inability to increase systolic BP by 20 mmHg
  or to 70 mmHg
• and/or an inability to attain a pulse rate
  lt100/min

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Failure of therapy

• After 6 hrs from time zero
• occurrence of haematemesis
• ?systolic BP of gt 20 mmHg
• ?pulse rate by 20/min from 6 hr time point
• 2 units or more of blood to keep Hb around 9 g/dL

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Early rebleeding

• gt 48 hrs from time zero but within 6 wks
• Reasons
• Severe initial bleeding
• Overly aggressive volume resuscitation
• Infection
• High hepatic venous pressure gradient
• Complications of endoscopic therapy
• Renal failure

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Late rebleeding

• After 6 wks
• Reasons
• High Child-Pugh score
• Large variceal size
• Continued alcohol use
• Hepatocellular carcinoma

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What to do when endoscopic treatment fails

• 10 to 20 of emergencies
• No data to support use of higher doses of
  octreotide or somatostatin
• Options
• 2nd attempt at endoscopic haemostasis
• Balloon tamponade
• TIPS
• Surgery

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BALLOON TAMPONADE 

• Sengstaken-Blakemore tube
• 250 cc gastric balloon, an esophageal balloon and
  a gastric suction port
• Initial control 30 to 90 of patients
• Major complications approx 14
• Risk of rebleed on deflation
• Temporary stabilization before more definitive
  treatment

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Sengstaken tube
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TIPS

• Transjugular intrahepatic portosystemic shunt
• Like side-to-side surgical portacaval shunts
  without GA or major surgery
• active bleed failed endoscopic medical
  treatment
• Poor surgical candidates
• 60 90 1-month survival vs 10 20 in surgery

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• TIPS

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Surgery

• Ideal surgical patient
• well preserved liver function who fails emergent
  endoscopic treatment and has no complications
  from bleeding or endoscopy
• Distal splenorenal shunt (Warren shunt)
• effective therapy for active variceal haemorrhage
  in experienced hands

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Surgery (contd)

• Esophageal transection
• effective as sclerotherapy
• troublesome suture line bleeding
• varices recur after variable period of time

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Surgery (contd)

• Sugiura procedure
• Controls bleed in 70 90
• Entire greater curve, distal 7cms of oesophagus
  upper 2/3rds of lesser curve devascularised
• Splenectomy not necessary
• Oesophageal transection not necessary already
  sclero / banded

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Gastric varices

• GLUE (N-butyl-cyanoacrylate, isobutyl-2-cyanoacryl
  ate) or thrombin more effective than sclero or
  banding
• TIPS bleeding control rates gt 90
• balloon-occluded injection sclerotherapy
• Surgery

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Endoscopic glue
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Prediction of patients at risk

• Varices at OG junction, gastric fundus
• Higher grade of oeso.varices
• "red signs at endoscopy
• Higher Child-Pugh score
• h/o previous variceal bleed
• Higher variceal pressure (endoscopic gauge)

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Prophylaxis against first bleed(Primary
Prophylaxis)

• all cirrhotics diagnostic endoscopy
• document varices
• determine risk of bleed
• Nonselective ß blockers
• lower portal pressure
• reduce risk of first bleed
• Endoscopic banding
• Intolerance to ß blockers
• Contraindications to ß blockers (asthma, renal
  failure)
• Higher varix grade

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Prevention of rebleed (Secondary Prophylaxis)

• 70 risk within 1 yr of bleed
• 70 of all untreated patients die within 1 yr of
  initial bleed
• Options
• endoscopic sclero / band ligation
• beta blockers and/or oral nitrates
• TIPS (Child A or B)
• Surgery (Child A)

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Prevention of rebleed (Secondary Prophylaxis)

• Beta blockers plus band ligation Combination
  therapy, better at preventing rebleed
• TIPS lesser rebleed, more expensive, more
  encephalopathy, same survival
• Surgery distal splenorenal shunt, better
  bleeding control but less survival, sclerotherapy
  better

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Prevention of rebleed(Secondary Prophylaxis)

• Orthotopic Liver transplantation 
• only treatment which corrects portal hypertension
  and liver failure
• long wait for an organ
• Survival ? 80 to 90 at 1 yr to
• ? 60 at 5 yrs

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THANKS
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Child Pugh score
Parameter 1 point 2 points 3 points
S. Bilirubin (mg/dl) lt 2 2 3 gt 3
Albumin (g/dl) gt 3.5 2.8 3.5 lt 2.8
Prothrombin time ( ? secs) 1 3 4 6 gt6
Ascites None Slight Moderate
Encephalopathy None Grade 1 2 3 4
A 5 to 6 points B 7 to 9
C 10 to 15